A nurse counseling a patient with a dissociative identity disorder should understand that the assessment of highest priority is:
a. Risk for self-harm
b. Cognitive functioning
c. Identification of drug abuse
d. Readiness to reestablish identity or memory
ANS: A
Assessments that relate to patient safety take priority. Patients with dissociative identity disorders may be at risk for suicide or self-mutilation; therefore the nurse must be alert for hints of hopelessness, helplessness and worthlessness, low self-esteem, and impulses to self-mutilate. The distracters are important assessments but rank beneath safety.
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a. An acute wound in which the patient has sutures placed when it happened b. A pressure ulcer that was treated with dressing changes and healed c. An acute wound in which surgical glue was used to close the wound d. A wound that was left open initially and closed later with sutures
While obtaining the medication history, a client tells the nurse that he takes acetaminophen every day. The nurse questions the client about the amount of the drug he takes in each dose and
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A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be:
1) "Your vital signs confirm that your infection is resolved; how do you feel?" 2) "I'll let your health care provider know so you can be discharged." 3) "Your vital signs are stable, but there are other things to assess." 4) "We still need to keep monitoring your temperature for a while."
Complementary and alternative therapies are becoming more commonly used in the U.S. Based on an understanding of how clients learn about these therapies, which client is most likely to use either a complementary or an alternative therapy?
A. An elderly couple on a fixed income without a computer at home B. A middle-aged woman who travels internationally for her job C. An adolescent male who plays many sports through school D. A young mother of three preschoolers who works part-time